Ex3 Status Epilepticus

Question 1

status epilepticus

Answer 1

continuous seizures >/= 5minutes or consecutive, intermittent seizures w/ no signs of consciousness for >/= 5 min between each episode

Question 2

refractory status epilepticus

Answer 2

SE that persists after standard treatment w/ at least 2 standard epileptic drugs (AED)

Question 3

Cause of refractory SE

Answer 3

NMDA receptor upregulation (increased excitation)

GABA receptor endocytosis (increased excitation, benzo-refractory state)

Question 4

More NMDA receptors you have

Answer 4

increased excitation

Question 5

inability for brain to control excess cortical electrical activity

Answer 5

status epilepticus

Question 6

Phase I (early phase)

Answer 6

initial 30 minutes of seizure activity

Question 7

Phase II (Late Phase)

Answer 7

after 30 minutes of continuous seizure activity

Question 8

types of SE

Answer 8

2 - convulsive SE and Non-convulsive SE

Question 9

SE is associated with

Answer 9

Negative outcomes:

• neuro deficit
• mortality w/in first 3 months
• risk of refractory SE w/ prolonged SE

Question 10

first line pharmacologic management

Answer 10

Lorazepam*, Midazolam

Question 11

Second line pharmacologic management

Answer 11

Valproate, (Fos)phenytoin, phenobarbital, levetiracetam

Question 12

Third line pharmacologic management (intubated)

Answer 12

midazolam infusion
pentobarbital infusion
propofol infusion
ketamine infusion

Question 13

Third line pharmacologic management (non-intubated)

Answer 13

lacosamide, topiramate, valproate

Question 14

MOA for management of SE

Answer 14

Dirty mechanism

Hit all sorts of sodium, GABA, NMDA channels

Question 15

DOC First line

Answer 15

Lorazepam

Question 16

risk of lorazepam over time

Answer 16

propylene glycol toxicity

Question 17

propylene glycol toxicity

Answer 17

severe hyperosmolar gap, metabolic acidosis, hypotension, multi-organ failure

Question 18

downside of using midazolam as 1st line

Answer 18

short acting

Question 19

Lorazepam dosages SE

Answer 19

4mg pushes (up to 8mg)

Question 20

Which Rx can have concentrations measured?

Answer 20

Fosphenytoin, Phenytoin

Question 21

AE Fosphenytoin

Answer 21

hypotension, arrhythmia (rate dependent) - don’t slam it in

Question 22

Dosing of Fosphenytoin

Answer 22

18-20 mg PE/kg IV

max 150 mg PE/min

Question 23

Dosing of Phenytoin

Answer 23

18-20 mg/kg IV

max 50 mg/min

Question 24

AE Phenytoin

Answer 24

hypotension, arrhythmia (rate dependent) - don’t slam it in

Purple glove syndrome, hepatotoxicity, propylene glycol

Question 25

AE valproic acid

Answer 25

hyperammonemia, thrombocytopenia

Question 26

RX intxn valproic acid

Answer 26

carbapenems (ANY)

Question 27

Keppra adverse effect

Answer 27

agitation

Question 28

Hepatic dysfunction - SE, which drug to use?

Answer 28

1. Keppra (renal elimination) | 2. Lacosamide

Question 29

Phenobarbiturate AE

Answer 29

propylene glycol toxicity

Question 30

lacosamide AE

Answer 30

generally well tolerated

Question 31

topiramate common side effect

Answer 31

metabolic acidosis

Question 32

pentobarbital considerations

Answer 32

- propylene glycol - target is burst suppression - reqs mechanical ventilation

Question 33

midazolam - as 3rd line agent

Answer 33

requires mechanical ventilation

Question 34

propofol AEs

Answer 34

propofol infusion syndrome, req's mechanical ventilation

Question 35

increased risk of propofol infusion syndrome

Answer 35

>80 mcg/kg/min for >48h

Question 36

propofol infusion syndrome

Answer 36

``` refractory bradycardia cardiac failure metabolic acidosis rhabdomyolysis hyperlipidemia enlarged liver renal failure ```

Question 37

Antidote for Isoniazide-induced seizures

Answer 37

IV pyridoxine

Question 38

Carbapenems should NOT be given with

Answer 38

valproate

Question 39

Phenobarb/pentobarbital effects on P450

Answer 39

potent inducer, other drugs will be decreased in efficacy

Question 40

Phenobarb/pentobarbital decrease levels of

Answer 40

carbamazepine, corticosteroids, lamotrigine, midazolam, fosphenytoin, valproate

Question 41

Phenytoin effects on P450

Answer 41

potent inducer, other drugs will be decreased in efficacy

Question 42

Phenytoin decreases levels of

Answer 42

carbamazepine, corticosteroids, azole antifungals, lamotrigine, midazolam

Question 43

Carbamazepine is a _______ of hepatic metabolism

Answer 43

inducer

Question 44

Carbamazepine effects midazolam by

Answer 44

CYP450 inducer - Midazolam will have reduced exposure

Question 45

Arithromycin/Erythromycin are _____ of hepatic metabolism

Answer 45

inhibitors

Question 46

Fluconazole is a ______ of hepatic metabolism

Answer 46

inhibitor

Question 47

Fluconazole will ______ levels of midazolam

Answer 47

decrease (d/t hepatic metabolism)

Question 48

Valproate is a ______ of hepatic metabolism

Answer 48

inhibitor

Question 49

Valproate will increase the exposure of

Answer 49

lamotrigene, nimodipine, phenytoin, phenobarbital, warfarin

Question 50

Common drug induced seizures

Answer 50

1. antidepressants - bupropion (most common), TCAs 2. pain medications (tramadol, meperidine) 3. immunosuppressants (calcineurin inhibitors: tacrolimus, cyclosporin) 4. others: lithium, local anesthetics, metoclopramide

Question 51

Drug induced seizures: ANTBX

Answer 51

Beta lactams - PCN, cephalosporins, carbapenems, monobactam Isoniazid Metronidazole

Question 52

Antipsychotics - induced seizures

Answer 52

haldol olanzipine quetiapine

Question 53

neuromuscular blocker resistance

Answer 53

phenytoin (induces CYP)

Question 54

topiramate - drug intxns

Answer 54

metabolic acidosis - additive

Question 55

Valproic acid + topiramate

Answer 55

hyperammonemia

Question 56

Prolongation of PR risk

Answer 56

Lacosamide + Beta Blockers, ca2+ channel blockers, fentanyl